When you start trying to measure customer satisfaction and give doctors a financial incentive for getting high marks from their patients, you’d better pay attention to what you’re measuring and what the doctors think they have to do to improve their scores.

I believe the biggest problem facing us in this realm is that in many other spheres of their lives doctors are customers, and so they have a sense of customer satisfaction from that side of the transaction. What does it take to create a satisfied customer? It’s quite simple. Figure out what the customer wants and give it to him.

So the patient has cold symptoms or a sore throat. The doctor thinks the patient must want an antibiotic. Why else would he be consulting a physician? To be told it’s a cold and advised to go to the drugstore and buy an off-the-shelf medicine to treat the symptoms?

The patient could have just watched TV commercials or asked the druggist at his local pharmacy if he wanted that. No, he must want something by prescription. So he gets an antibiotic for his head cold, sore throat, or chest cold, some illness caused by a virus. Antibiotics don’t work against viruses, only bacteria. So there is no potential for benefit – only harm. But the illness gets better on its own, because that’s how these things go, and the patient, who did not go on to have eternal bronchitis, figures the antibiotic must have helped. So what will he do every time he gets a viral respiratory infection henceforth and forever? Right. And all those unnecessary antibiotic prescriptions will help promote the development of resistant bacteria.

The doctor who wants to practice good medicine and still get high patient satisfaction scores can just take some extra time and explain to the patient why antibiotics are not indicated, how they are more likely to harm than help, and how they contribute to the problem of resistant bacteria.

And then he can hope that his scores will be as high as those of his colleague in the next office who just writes the antibiotic prescriptions, taking a fraction of the time and mental effort. Good luck with that.

Then there is the challenge of diagnostic testing. Patients like tests. They believe in tests. They have no idea that a smart doctor can often figure out what’s wrong with them by eliciting a detailed account of their symptoms and performing a focused physical examination, without ordering any tests at all. Most of the time, test results serve primarily to confirm the diagnosis that was already established in the physician’s mind.